21.1 General Patient Guidelines for the Treatment of Ulcers or Wounds at Home
5Take care to wash your hands with soap and water before and after the treatment.
5 When the dressing is changed, any materials removed from the wound should be placed directly into a plastic bag set aside earlier for that purpose. Make sure that the infected dressings do not come into contact with the floor, the furniture, or any other object, so as to avoid as far as possible any spread of infectious bacteria to the surroundings.
Appendix: Guidelines for Patients
and Medical Staff 21
Contents
21.1 General Patient Guidelines for the Treatment of Ulcers or Wounds at Home 255
21.2 Patient Guidelines for the Management of Skin Ulcers Caused
by Venous Insufficiency 256
21.3 General Guidelines for Patients with Diabetes or Peripheral Arterial Disease 256
21.4 Treatment of Edema 257 References 257 21.5 Guidelines for Nurses:
Outpatient Management of Cutaneous Ulcers 258 References 259
5The skin around the wound may be cleaned using a very dilute, mild soap. Ensure that all the residual soap is thoroughly rinsed off, using a gentle stream of lukewarm water.
Avoid using soap directly on the wound.
5After being rinsed with water, the wound should be dried by gentle patting/dabbing only. Never scrub or rub the wound.
5Any medical substance that needs to be placed on the wound bed should be applied using an object such as a spatula, or tongue depressor. Never apply the substance directly from its container, and never use bare fin- gers to apply it.
5To remove dressings that have be- come stuck to the wound because of dried secretions on the wound sur- face, moisten them with saline or tap water and leave them wet for a few minutes. They can usually then be removed relatively easily without causing any damage to the bed of the wound.
5Ensure that the dressing is not too tight or pressing too hard on the wound, since a tightly applied dress- ing may interfere with the blood flow.
5Use an elastic net dressing (e.g., fle- xible elastic net bandages; stockin- ette) to hold the dressing on the wound. Avoid the use of adhesive plaster directly on the skin.
5Smoking is strictly forbidden!!!
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21.2 Patient Guidelines for the Management of Skin Ulcers Caused by Venous Insufficiency
5Avoid standing as much as pos- sible.
5While seated, make sure your legs are elevated, if possible slightly above the level of your buttocks.
5When lying down, it is advisable to elevate the legs slightly on a cushion or folded blanket.
5It is advisable to walk every day for at least 30–60 min; do not stand still during this time.
5When seated or lying down, move your legs (twisting, cycling motion, etc.) several times a day for 10–15 min each time.
5If your doctor advises you to use support stockings, you should put them on in the morning, after your legs have been elevated for a few hours, so that your legs will not be swollen when you put the stockings 5on.Smoking is strictly forbidden!!!
21.3 General Guidelines for Patients with Diabetes or Peripheral Arterial Disease
The following guidelines should be imple- mented by patients with diabetes or peri- pheral arterial disease, in order to prevent formation of cutaneous ulcers.
5 Wash your feet at least once a day with a mild soap under running water. Make sure you rinse off all traces of the soap, particularly between the toes.
5 Use only lukewarm, not hot water.
5 After washing, dry your feet thoroughly, including between the toes, since moisture in that area can lead to infections. Usually a normal towel is not adequate; use absorbent paper in addition.
5 It is recommended you walk at least 30–60 min every day. It is also advisable to move your legs while lying down or sitting (twisting or cycling movements, etc.) several times a day, for 10–15 min each time. In the case of a neuropathic ulcer consult your doctor as to the appropriate mode of physical activity and pressure off-loading.
5 Cutting toenails: Avoid cutting the corners; trim the toenails straight across. If necessary, get someone to help you, so you don’t injure your- self. Do not ‘dig’ with a sharp in- strument in the angle between the nail and the flesh.
5 Examine your legs and feet once a day, using a mirror, or get someone to help if necessary.
5 Treatment of wounds, corns, blis- ters should be carried out only under medical supervision. Should areas of dry skin, rashes, scaling, or changes in the skin color ap- pear, seek medical advice.
5 Cold and heat injury: Avoid expo- sure to cold; keep the feet warm in winter. However, do not sit too close to a heater or fire. Don’t use a hot water bottle. Do not use an electric blanket without a thermostat. Be- fore washing your feet, test the wa- ter temperature with your hand.
5 Wear comfortable, well-fitting shoes. A poorly fitted shoe may cause corns, because of uneven pressure distribution on the foot when walking. Before putting your shoes on, shake them out to re- move any small stones. Don’t wear shoes without socks. Cotton socks
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are preferable. Change your socks at least once a day. Avoid sandals or thongs, since they do not pro- tect the foot from injury.
5Smoking is strictly forbidden!!!
21.4 Treatment of Edema
Once the cause of edema has been identified, treatment should be done accordingly (see Chap. 7).
In addition, the following steps should be considered:
5Elevation of the extremities: The pa- tient should be given clear instruc- tions to raise the affected extremity.
In the case of leg ulcers the patient should be instructed to avoid pro- longed standing as much as possible and to raise the leg while sitting or lying down.
5Physical activity: The patient should be advised to engage in physical ac- tivity and to exercise the leg mus- cles. Physical activity can reduce the degree of leg edema [1, 2].
5Physical therapy: The patient should be referred for a special form of therapy known as manual lymph drainage. This is a massage tech- nique designed to reduce edema. It is effective for edema of the lower extremities and can aid in the heal- ing of cutaneous ulcers associated with edema [2–9]. Kurtz et al. [8]
found that this procedure may lead to the mobilization of up to 1 l of urine from reabsorption and trans- port of interstitial fluid. Gentle pres- sure is applied to lymph nodes and lymph vessels with the finger tips to evacuate lymphatic content. The rhythm of applied pressure is differ- ent from that of traditional massage
techniques [3, 4]. The basic principle is that central regions of lymph drainage, such as the lower abdo- men and proximal thigh, should be emptied initially to provide space for the drainage of peripheral fluid.
After the proximal region of a limb has been cleared of its lymph, distal areas are massaged to mobilize the fluid proximally. The scheduling of therapeutic sessions depends on the size of the ulcer, the amount of ede- ma, and the patient’s general condi- tion. It is usual to conduct two to three sessions per week [4], but dai- ly sessions should be considered under certain circumstances.
5Compression therapy is done using stockings or elastic bandages. Com- pression therapy has a proven value as a means of treating venous insuf- ficiency and its ensuing leg ulcers [10–13].
5Administration of diuretics should be considered, depending on the cli- nical data.
References
1. Ciocon JO, Galindo Ciocon D, Galindo DJ: Raised leg exercises for leg edema in the elderly. Angiology 1995; 46 : 19–25
2. Casley-Smith JR, Casley-Smith JR: The nature of complex physical therapy. In: Casley-Smith JR, Cas- ley-Smith JR (eds) Modern Treatment for Lymphoe- dema, 5th revised edn. Adelaide: The Lymphoedema Association of Australia. 1997; p 131
3. Casley-Smith JR, Casley-Smith JR: Massage tech- niques for lymphoedema. In: Casley-Smith JR, Cas- ley-Smith JR (eds) Modern Treatment for Lymphoe- dema, 5th revised edn. Adelaide: The Lymphoedema Association of Australia. 1997; pp 134–152
4. Stahel HU: Manual Lymph Drainage. Curr Probl Dermatol 1999; 27 : 148–152
5. Hoffmann A, Petzoldt D: Manual lymph drainage.
Hautarzt 1978; 29 : 463–466
6. Evrard-Bras M, Coupe M, Laroche JP, et al: Manual lymphatic drainage. Rev Prat 2000; 50 : 1199–1203 7. Derdeyn A, Aslam M, Pflug JJ: Manual lymph drain-
age – mode of action. Lymphology 1994; 27 [Suppl] : 527–529
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manual lymph drainage massage on blood compo- nents and urinary neurohormones in chronic lym- phedema. Angiology 1981; 32 : 119–127
9. Francois A, Richaud C, Bouchet JY, et al: Does medi- cal treatment of lymphedema act by increasing lymph flow? Vasa 1989; 18 : 281–286
10. Partsch H: Compression therapy for venous ulcers.
Curr Probl Dermatol 1999; 27 : 130–140
11. Cullum N, Nelson EA, Fletcher AW, et al: Compres- sion for venous leg ulcers (Cochrane Review). In:
The Cochrane Library. Issue 1, 2003; Oxford : Update Software
12. Phillips TJ, Dover JS: Leg ulcers. J Am Acad Derma- tol 1991; 25 : 965–987
13. Yasuhara H, Shigematsu H, Muto T: A study of the advantages of elastic stockings for leg lymphedema.
Int Angiol 1996; 15 : 272–277
21.5 Guidelines for Nurses:
Outpatient Management of Cutaneous Ulcers
5Warn the patient not to touch any object, furniture, or any other item in the clinic unnecessarily, to reduce the spread of bacteria to the sur- roundings.
5Both the patient and the nurse should wash their hands before and after the treatment. Show the pa- tient how to wash his/her hands correctly. Hands should be washed under running water, for about 15–20 sec, with 3–5 ml of a cleaning agent [1]. Another accepted disin- fecting method is to use an alcohol- based hand-rub solution (contain- ing about 70% alcohol). Recently, the latter has been documented as the best method for reducing trans- mission of infection [2, 3].
5The patient should avoid placing his/her treated foot directly on the floor. The treated foot should be placed on a stool covered by plastic and a clean cloth or sheet [4]
(Fig. 21.1).
5Should the ulcer need to be rinsed extensively with saline, ensure that there are sheets of plastic on the floor or bench.
5Place a plastic bag near the patient, in which you can readily dispose of all the dressing materials removed from the ulcer (Fig. 21.2). Ensure that used dressing materials re- moved from the ulcer do not come into contact with the floor, the fur- niture, or any other object in the clinic.
5Throughout the treatment proce- dures the nurse must wear gloves. It is advisable to change the gloves af- ter removing the old dressing. Use a new pair of gloves when applying the fresh dressing to the wound.
5Enter information into the patient’s record after completing the dressing procedure, removing the gloves, and washing your hands.
5Between one patient and the next, clean the treatment area with anti- septic solution.
5After treating an ulcer that is likely to be heavily infected (such as a cu- taneous ulcer known to contain methicillin-resistant Staphylococcus aureus or resistant Pseudomonas strains) or a heavily secreting ulcer, clean the treatment room thorough- ly with soap and sodium-hypochlor- ite solution. Free available chlorine at 500 ppm is documented as being the most effective compound against most nosocomial pathogens [5].
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References
1. Larson E: APIC guideline for hand washing and hand antisepsis in health-care settings. Am J Infect Control 1995; 23 : 251–269
2. Hugonnet S, Pittet D: Hand hygiene revisited: Les- sons from the past and present. Curr Infect Dis Rep 2000; 2 : 484–489
3. Teare L, Cookson B, Stone S: Hand hygiene. Use alco- hol hand rub between patients: they reduce trans- mission of infection. Br Med J 2001; 323 : 411–412
4. Shai A, Bilenko N, Ben-Zeev R, et al: Use of infection control procedures in an out-patient clinic for leg ul- cers and the rate of contamination with methicillin- resistant Staphylococcus aureus. Wounds 2004; 16 : 193–200
5. Zaidi M, Wenzel RP: Disinfection, sterilization, and control of hospital waste. In: Mandell GL, Bennett JE, Dolin R (eds) Mandell, Douglas and Bennett’s Prin- ciples and Practice of Infective Diseases, 5th edn.
Philadelphia: Churchill Livingstone. 2000; pp 2995–
3005
Fig. 21.1.The patient’s leg is placed on a stool Fig. 21.2.A plastic bag is used for disposal of the dress- ing materials removed from the ulcer
